Form DC-173 A (LA) 1/98_ - New Jersey



|Form DC-173 A (LA) 1/02 |NEW JERSEY DEPARTMENT OF TRANSPORTATION |Sheet 1 of | |

|Construction Order |LOCAL AID |Order No. | |

| |FEDERAL AID CHANGE ORDER |Order Letter | |

| | |Date | |

|Project | |

|Federal Project No. | |Doc. No. | |

|Contractor | |

You are hereby directed to implement the following changes in accordance with the provisions of the specifications for this contract.

Location of proposed order

Nature and reason of order:

Extension Reduction of time recommended this order

|CONTRACT AMOUNT | |ROAD | |BRIDGE | |TOTAL | | |CONTRACT TIME |

|Amount of original | | | | | | | | |Original Completion Date _____________ |

|contract |$ | |$ | |$ | | | |Adjustment This Order (+ or -) _________ |

|Adjusted amount | | | | | | | | |Previous Adjustments (+ or -) _________ |

|based on order Nos. |$ | |$ | |$ | | | |Adjusted Completion Date ____________ |

| | | | | | | | | | |

|ORDER NO. _______ | |Road | |Bridge | |Other | | |RESERVED FOR FHWA OR F.T.A. |

| | | | | | | | | | |

| | |Road | |Bridge | |Total | | | |

|Extra Work |$ | |$ | |$ | | | | |

|Increases |$ | |$ | |$ | | | | |

|Decreases |$ | |$ | |$ | | | | |

|Total |$ | |$ | |$ | | | | |

|Recommended: | | | | | | |

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|County / Municipal / Sponsor’s Engineer | |Date | | | | |

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|Approved: | | | |Approved for Funding Participation Purposes: | | |

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|Presiding Officer | |Date | |Manager, Local Aid, District # | |Date |

| |ALTERNATE PROCEDURES PROJECTS |

| |This order is approved for Federal participation. |

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| | |Director, Local Aid & Economic Development | |Date | |

|Accepted: | | | |CONTRACTS PAYABLE SECTION | | |

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|Contractor’s Authorized Signature | |Date | |Reviewed by ________________________ | |________ |

| | | | | | |Date |

|Name | | |Input Submitted by ___________________ | |________ |

| | | | | |Date |

|Title | | |Certification of Funds | | |

| | | | | | |

| Unprotested | |___________________________________ | |________ |

| Protested by letter dated _________ attached. | |Director of Accounting & Auditing | |Date |

|Form DC-173 A (LA) 8/02 |NEW JERSEY DEPARTMENT OF TRANSPORTATION |Sheet ____ | |

| | |of | |

|Construction Order |LOCAL AID |Order No. | |

| |FEDERAL AID CHANGE ORDER |Order Letter | |

| | |Date | |

|Project | |

|Federal Project No. | |Doc. No. | |

|Contractor | |

|ITEM NO. |DESCRIPTION |QUANTITY (+/-) |UNIT PRICE |AMOUNT |

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|Amount of Original Amount |$ | |

|Adjusted Amount Based on Change | | |

|Order No. _____, _____, _____ |$ | |

|Total Change (+ or -) |$ | |

|% Change in Contract | |% |

|[(+) Increase or (-) Decrease] | | |

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